Diagnostic and Therapeutic Injections

Some of the diagnostic and/or therapeutic options available in the management
of back pain, neck pain and other pain that originates from the spine are the use of epidural injections,
facet injections and discography. These techniques have become very popular
over the years due to their success in the conservative management of
certain types of pain originating from the spine.

Epidural injections using corticosteroids have been found to be
an effective treatment for people who are suffering from some types of
low back pain, neck pain and radicular pain (pain in the upper or lower
limb due to nerve inflammation in the spine). Lower limb radicular pain
is also known as “sciatica”. Commonly, nerves that supply
the neck/upper limbs or the low back/lower limbs are compressed/irritated
inside the spine by a bulging or herniated disc, an arthritic bone spur,
scar tissue or a combination of these factors. This causes the nerve to
become irritated, inflamed and swollen; the more swollen it becomes, the
more it pushes against local structures setting up an inflammatory reaction/vicious
cycle. A corticosteroid is a powerful anti-inflammatory medication that
acts to decrease the inflammation and swelling of this nerve, thereby
breaking this vicious cycle of swelling/irritation and providing pain
relief. The epidural space is an air pocket that surrounds the spinal
cord and the spinal nerves. One commonly hears of the use of epidural
anesthetic injections for pregnant women during labor and these
are also used for surgical anesthesia during hernia, knee or leg surgery.
This space can be accessed effectively by pain management specialists
for depositing anti-inflammatory or other pain relieving
medication around the spinal nerves thereby producing more effective and
long lasting reprieve from some types of debilitating pain, such as back pain and neck pain. With the use
of newly developed x-ray equipment we can enter the epidural space safely
and more precisely from several directions and thus provide more effective
coverage of the inflamed nerves. Using a translaminar or “down the
middle” approach into a canal that has been narrowed by degeneration,
inflammation and/or scarring allows medication to surround nerves and
flow onto the deep ligaments and parts of the outer portions of the disc
itself and can relieve some types of low back pain and neck pain. A transforaminal
or “from the side” approach allows the medication to be injected
through a tunnel that has been narrowed and relieves lower or upper limb
pain that was produced from irritation of the large nerves that exit through
these tunnels. A caudal or “through the tailbone” approach
provides an opportunity for a specially made catheter to navigate through
this space and allows for better visualization of swollen nerves, makes
it possible to break-up scar tissue formation from previous spine surgery
and permits more medication to be delivered to multiple levels of the
spine at the same time.

Facet injections are effective for some cases of localized low
back pain and neck pain. Small amounts of steroid and/or local anesthetic medication
are injected into these small joints on either side of the spine. If these
joints move more easily, allowing the spine to rotate without restriction and without pain, then the diagnosis
is made and the injections, if steroid is used, proves therapeutic. If
these results are only temporary then there is a more permanent way to
relief using radio waves to burn and destroy the small nerve endings that
innervate these joints. These techniques of using radio waves can provide
long lasting relief from pain emanating from these facet joints.

Discography allows us to understand the role of the disc or “shock
absorber” as a pain producer. Discography is performed via injecting
a disc with small amounts of fluid and observing the results along with
obtaining pictures of the discs (discograms). By measuring the pressure
recorded in the disc at time of injection, how much fluid the disc can
hold, and whether the injection allows a build up of pressure reproducing
one’s pain are vital to diagnosing the disc as generating pain.
This pain is produced via pressure on certain types of internal tears
of the disc that will cause pain independent of the local structures surrounding
the disc (such as the spinal nerves and facets discussed above). There
can be tears inside the disc caused from degeneration or trauma. These
tears can weaken the disc and lead to bulging or these tears can enlarge
and allow for herniation of the internal contents of the disc to occur.
Bulging discs and herniations of the inner disc materials put pressure
on the surrounding nerves and in the case of the herniation, chemically
irritate the surrounding nerves. Discs can eventually flatten with subsequent
loss of liquid. People with disc pain can have surgery as an option but
newer less invasive treatments can be offered such as using heat waves
to repair tears, vaporizing disc material to reduce volume and ease the
pressure on the bulging areas and injecting nutraceuticals, vitamins and
herbal remedies to strengthen the disc material.

As one can see we are able to use spinal injections to both diagnose
and treat pain of spinal origin through the use of carefully guided needle
positioning, proper solutions and deposition of these solutions at precise
locations. The use of injections (anesthetic and/or steroid) is also quite
useful for many painful musculoskeletal conditions of the upper and lower
limbs such as shoulder bursitis which is an inflammation of the small
sac of fluid (bursa) that is located near the rotator cuff muscles. Other
examples of conditions that respond to the above-described techniques
include, but are not limited to, tennis elbow, knee arthritis, ankle sprain
and heel spur syndrome/plantar fasciitis. Consider contacting your Orthopaedic
medicine specialist for non-operative treatment for these conditions.